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Yakout A, Elli EF, Kumbhari V, Bakheet N. Endoscopic therapies for bariatric surgery complications. Curr Opin Gastroenterol 2024:00001574-990000000-00153. [PMID: 38900492 DOI: 10.1097/mog.0000000000001047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
PURPOSE OF REVIEW The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of endoscopic therapies for bariatric surgery complications. RECENT FINDINGS The field of interventional endoscopy now presents a range of minimally invasive procedures for addressing postbariatric complications. Lumen-opposing metal stents have emerged as a reliable solution for managing gastrojejunal strictures following Roux-en-Y gastric bypass, whether with or without associated leaks. Additionally, they serve as a conduit for performing endoscopic retrograde cholangiopancreatography (ERCP) post-RYGB via EUS-directed ERCP (EDGE). Gastric peroral endoscopic myotomy, originally designed for gastroparesis, has demonstrated effectiveness in treating postgastric sleeve stenosis, particularly the challenging helical stenosis cases. Furthermore, innovative endoscopic antireflux techniques are showing encouraging outcomes in addressing gastroesophageal reflux disease (GERD) following sleeve gastrectomy. Additionally, several modifications have been proposed to enhance the efficacy of transoral outlet reduction (TORe), originally developed to treat weight regain due to gastrojejunal anastomotic issues post-RYGB. SUMMARY Endoscopic management of bariatric surgery complications is continuously evolving. The development of new techniques and devices allows endoscopists to provide novel, minimally invasive alternatives that were not possible in the near past. Many techniques, however, are limited to expert centers because they are technically demanding, and specialized training in bariatric endoscopy is still required.
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Affiliation(s)
| | - Enrique F Elli
- Department of General Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine
| | - Nader Bakheet
- Division of Gastroenterology and Hepatology, Department of Medicine
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Sadiku F, Alceste D, Serra M, Hehl SJ, Gero D, Thalheimer A, Bueter M, Widmer J. Comparative analysis of linear- and circular-stapled gastrojejunostomies in Roux-en-Y gastric bypass: a focus on postoperative morbidity using the comprehensive complication index. Langenbecks Arch Surg 2024; 409:120. [PMID: 38602565 PMCID: PMC11009775 DOI: 10.1007/s00423-024-03303-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 04/03/2024] [Indexed: 04/12/2024]
Abstract
PURPOSE The linear-stapled (LSA) and the circular-stapled anastomosis (CSA) are the two most commonly performed techniques for the gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (RYGB). This study compared the outcome after both techniques with special focus on postoperative morbidity using the comprehensive complication index (CCI). METHODS Five hundred eighty-eight patients operated between 01/2010 and 12/2019 were included in the final analysis and divided in two cohorts according to the surgical technique of the GJ (LSA (n = 290) or CSA (n = 298)). Before 09/2016, the CSA was exclusively performed for the GJ, while after 09/2016, the LSA was solely used. RESULTS The mean CCI for patients with Clavien-Dindo complication grade ≥ 2 within the first 90 days after RYGB was 31 ± 9.1 in the CSA and 25.7 ± 6.8 in the LSA group (p < 0.001), both values still below the previously published benchmark cutoff (≤ 33.73). The C-reactive Protein (CRP)-levels on postoperative days (POD) 1 and 3 as well as the use of opioids on POD 1 were significantly higher in the CSA- than in the LSA-group (all p < 0.001). There were significantly more internal herniations in the CSA group during the first 24 postoperative months (p < 0.001). CONCLUSION Patients after RYGB with CSA were found to have higher CCI values during the first 90 PODs compared to patients in which the LSA was applied. To achieve optimal outcomes in terms of patient morbidity, the LSA seems to be the superior technique for GJ in RYGB.
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Affiliation(s)
- Floni Sadiku
- Department of Surgery, Maennedorf Hospital, Maennedorf Zurich, Zurich, Switzerland
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland
| | - Daniela Alceste
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8006, Zurich, Switzerland
| | - Michele Serra
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8006, Zurich, Switzerland
| | - Stefanie Josefine Hehl
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8006, Zurich, Switzerland
| | - Daniel Gero
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8006, Zurich, Switzerland
- Department of Surgery, Maennedorf Hospital, Maennedorf Zurich, Zurich, Switzerland
| | - Andreas Thalheimer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8006, Zurich, Switzerland
- Department of Surgery, Maennedorf Hospital, Maennedorf Zurich, Zurich, Switzerland
| | - Marco Bueter
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8006, Zurich, Switzerland.
- Department of Surgery, Maennedorf Hospital, Maennedorf Zurich, Zurich, Switzerland.
| | - Jeannette Widmer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8006, Zurich, Switzerland
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Jawhar N, Sample JW, Salame M, Marrero K, Tomey D, Puvvadi S, Ghanem OM. The Trajectory of Revisional Bariatric Surgery: Open to Laparoscopic to Robotic. J Clin Med 2024; 13:1878. [PMID: 38610643 PMCID: PMC11012271 DOI: 10.3390/jcm13071878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/16/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Metabolic and bariatric surgery (MBS) is the most effective therapeutic intervention for patients with obesity, with sleeve gastrectomy (SG) being the most commonly performed primary MBS procedure. Long-term studies have demonstrated that 15-20% of patients require revisional bariatric surgery (RBS) due to weight-related issues or surgical complications. Despite the gold standard being laparoscopic revision, there are other available approaches such as open or robotic-assisted. An extensive literature review was performed for articles from their inception to February 2024. A descriptive review of MBS procedures (SG, Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileostomy (SADI) and biliopancreatic diversion-duodenal switch (BPD-DS)) was carried out to report and compare outcomes between primary and revisional bariatric surgery. A similar review was conducted to compare outcomes of revisional approaches (open, laparoscopic, robotic). RYGB remains the dominant RBS with a similar safety profile compared to revisional SADI and BPD-DS. In terms of the RBS surgical approach, all three options showed comparable short and long-term outcomes, with robotic RBS being associated with longer operative time and variable length of stay. Additional long-term studies are required to further validate our conclusions.
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Affiliation(s)
- Noura Jawhar
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA; (N.J.)
| | - Jack W. Sample
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA; (N.J.)
| | - Marita Salame
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA; (N.J.)
| | - Katie Marrero
- Carle Foundation Hospital General Surgery Residency, Champaign, IL 61801, USA
| | - Daniel Tomey
- Department of General Surgery, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Suraj Puvvadi
- College of Health Solutions, Arizona State University, Phoenix, AZ 85004, USA
| | - Omar M. Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA; (N.J.)
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Gala K, Brunaldi V, Abu Dayyeh BK. Endoscopic Management of Surgical Complications of Bariatric Surgery. Gastroenterol Clin North Am 2023; 52:719-731. [PMID: 37919023 DOI: 10.1016/j.gtc.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Bariatric surgery, although highly effective, may lead to several surgical complications like ulceration, strictures, leaks, and fistulas. Newer endoscopic tools have emerged as safe and effective therapeutic options for these conditions. This article reviews post-bariatric surgery complications and the role of endoscopy in their management.
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Affiliation(s)
- Khushboo Gala
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA
| | - Vitor Brunaldi
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA.
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Hand-Sewn Gastrojejunostomy In Situ to Solve Acute Anastomotic Stricture Due to Submucosal Tunneling in Gastric Bypass. Obes Surg 2023; 33:1622-1624. [PMID: 36922466 DOI: 10.1007/s11695-023-06533-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/18/2023]
Abstract
Roux-en-Y gastric bypass (RYGB) is the second most widely used bariatric surgical procedure for morbid obesity and its related comorbidities. Anastomotic stricture is one of the major complications after RYGB. Submucosal tunneling is a rare cause of anastomotic stricture or occlusion, and clinical symptoms will appear soon after surgery. We present our technical suggestions to perform a hand-sewn gastrojejunostomy in situ when the gastric pouch is too small and the tissue is not enough to be resected to solve acute anastomotic stricture due to submucosal tunneling in gastric bypass.
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Endoscopic removal of a retained esophageal stent using the stent-in-stent technique. VideoGIE 2022; 7:439-441. [DOI: 10.1016/j.vgie.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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7
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De Simone B, Chouillard E, Ramos AC, Donatelli G, Pintar T, Gupta R, Renzi F, Mahawar K, Madhok B, Maccatrozzo S, Abu-Zidan FM, E Moore E, Weber DG, Coccolini F, Di Saverio S, Kirkpatrick A, Shelat VG, Amico F, Pikoulis E, Ceresoli M, Galante JM, Wani I, De' Angelis N, Hecker A, Sganga G, Tan E, Balogh ZJ, Bala M, Coimbra R, Damaskos D, Ansaloni L, Sartelli M, Pararas N, Kluger Y, Chahine E, Agnoletti V, Fraga G, Biffl WL, Catena F. Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines. World J Emerg Surg 2022; 17:51. [PMID: 36167572 PMCID: PMC9516804 DOI: 10.1186/s13017-022-00452-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/16/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. METHOD A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. CONCLUSIONS The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy-Ile de France, France.
| | - Elie Chouillard
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy-Ile de France, France
| | - Almino C Ramos
- GastroObesoCenter Institute for Metabolic Optimization, Sao Paulo, Brazil
| | - Gianfranco Donatelli
- Interventional Endoscopy and Endoscopic Surgery, Hôpital Privé Des Peupliers, Paris, France
| | - Tadeja Pintar
- Department of Abdominal Surgery, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Rahul Gupta
- Division of Minimally Invasive Surgery and Bariatrics, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Federica Renzi
- General Surgery and Trauma Team, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milano, Milan, Italy
| | - Kamal Mahawar
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Brijesh Madhok
- East Midlands Bariatric and Metabolic Institute, University Hospitals of Derby and Burton NHS Trust, Derby, UK
| | - Stefano Maccatrozzo
- Department of Bariatric Surgery, Istituto Di Cura Beato Matteo, Vigevano, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Salomone Di Saverio
- Department of Surgery, Madonna Del Soccorso Hospital, San Benedetto del Tronto, Italy
| | - Andrew Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Francesco Amico
- Department of Surgery, John Hunter Hospital and The University of Newcastle, Newcastle, MSW, Australia
| | - Emmanouil Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Joseph M Galante
- University of California, Davis 2315 Stockton Blvd., Sacramento, CA, 95817, USA
| | - Imtiaz Wani
- Government Gousia Hospital, Srinagar, Kashmir, India
| | - Nicola De' Angelis
- Service de Chirurgie Digestive Et Hépato-Bilio-Pancréatique - DMU CARE, Hôpital Henri Mondor, Paris, France
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Edward Tan
- Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA, USA
| | - Dimitrios Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Luca Ansaloni
- Department of Surgery, Pavia University Hospital, Pavia, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Nikolaos Pararas
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Elias Chahine
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy-Ile de France, France
| | - Vanni Agnoletti
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Gustavo Fraga
- School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Walter L Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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Ong HI, Robertson J, van Rijnsover M, Booth M. Novel Use of Lumen-Apposing Metal Stent in the Management of Gastrojejunal Stricture Perforation During Endoscopic Dilatation. Obes Surg 2022; 32:3213-3214. [PMID: 35831530 DOI: 10.1007/s11695-022-06202-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Hwa Ian Ong
- Department of General Surgery, Waitemata District Health Board, 124 Shakespeare Road, Takapuna, Auckland, 0620, New Zealand.
| | - Jason Robertson
- Department of General Surgery, Waitemata District Health Board, 124 Shakespeare Road, Takapuna, Auckland, 0620, New Zealand
| | - Marius van Rijnsover
- Department of Gastroenterology, Waitemata District Health Board, 124 Shakespeare Road, Takapuna, Auckland, 0620, New Zealand
| | - Michael Booth
- Department of General Surgery, Waitemata District Health Board, 124 Shakespeare Road, Takapuna, Auckland, 0620, New Zealand
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Khrucharoen U, Weitzner ZN, Chen Y, Dutson EP. Incidence and risk factors for early gastrojejunostomy anastomotic stricture requiring endoscopic intervention following laparoscopic Roux-en-Y gastric bypass: a MBSAQIP analysis. Surg Endosc 2022; 36:3833-3842. [PMID: 34471978 DOI: 10.1007/s00464-021-08700-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/23/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Gastrojejunostomy (GJ) stricture is one of the most commonly recognized complications following laparoscopic Roux-en-Y gastric bypass (LRYGB). The risks involving the formation of early GJ stomal stenosis are largely unknown. The aims of this study are to evaluate the rate and risk factors associated with GJ stricture in patients requiring esophagogastroduodenoscopy (EGD) within 30 days after LRYGB. METHODS This is a retrospective study of patients who underwent EGD for GJ stricture following LRYGB. Data were retrieved from MBSAQIP database from 2015 to 2018. Descriptive, bivariate, and logistic regression analyses were performed. Those who had reoperation, readmission, and intervention for other indications rather than GJ stricture were excluded from the risk factor analysis. RESULTS 760,076 patients underwent bariatric surgery. Of these, 184,660 (24.3%) underwent LRYGB and 875 had GJ stricture within 30 days postoperatively. The overall incidence of early GJ stricture after LRYGB was 4.7 per 1000 person-years. The incidence decreased from 6.2 to 3.4 per 1000 person-years during the 4-year period. 85% of patients with GJ stricture required therapeutic intervention. Median (IQR) day to the first endoscopic intervention was 25 (21-28) days. The overall 30-day readmission rate was 40%. 30-day reoperation rate due to GJ stricture was 5.6%. No 30-day mortality occurred. Factors independently associated with an increased risk for early GJ stricture include concurrent hiatal hernia repair (Adjusted Odds Ratio-AOR 1.8, 95% CI 1.5-2.2), revision case (AOR 1.4, 95% CI 1.1-1.6), African American (AOR 1.4, 95% CI 1.2-1.7), gastroesophageal reflux disease-GERD (AOR 1.4, 95% CI 1.2-1.5), drain placement (AOR 1.3, 95% CI1.1-1.4), and routine postoperative swallow study (AOR 1.3, 95% CI 1.1-1.50). CONCLUSION The incidence of early GJ stricture following LRYGB decreased at MBSAQIP-accredited centers over the review period. Patients having additional manipulation at or around GJ were at risk of developing early GJ stricture after LRYGB.
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Affiliation(s)
- Usah Khrucharoen
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA.,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA.,UCLA Center for Advanced Surgical & Interventional Technology (CASIT), Los Angeles, CA, USA
| | - Zachary N Weitzner
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA.,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA.,UCLA Center for Advanced Surgical & Interventional Technology (CASIT), Los Angeles, CA, USA
| | - Yijun Chen
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA.,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA
| | - Erik P Dutson
- Department of Surgery, Section of Minimally Invasive and Bariatric Surgery, David Geffen School of Medicine at University of California, Box 956904, 72-239 CHS, Los Angeles, CA, 90095, USA. .,UCLA Center for Obesity and METabolic Health (COMET), Los Angeles, CA, USA. .,UCLA Center for Advanced Surgical & Interventional Technology (CASIT), Los Angeles, CA, USA.
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Ayuso SA, Robinson JN, Okorji LM, Thompson KJ, McKillop IH, Kuwada TS, Gersin KS, Barbat SD, Bauman RW, Nimeri A. Why Size Matters: an Evaluation of Gastric Pouch Size in Roux-en-Y Gastric Bypass Using CT Volumetric Analysis and its Effect on Marginal Ulceration. Obes Surg 2022; 32:587-592. [PMID: 34985616 DOI: 10.1007/s11695-021-05850-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/26/2021] [Accepted: 12/13/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Marginal ulceration (MU) is a common long-term complication following Roux-en-Y gastric bypass (RYGB). The causes of MU after RYGB are multifactorial and include surgical technique of constructing the gastrojejunal anastomosis (GJA). The purpose of this study is to evaluate the relationship between gastric pouch size in RYGB and MU using CT volumetrics. MATERIAL AND METHODS Patients were retrospectively identified who underwent esophagogastroduodenoscopy (EGD) following RYGB at a tertiary care teaching hospital. Measurement of gastric pouch size was performed using 3-D CT software. Standard statistical methods were used, a univariate comparison was performed between MU and non-MU patients followed by a propensity-matched comparison to control for factors known to affect MU, and a propensity-matched subgroup analysis was also performed. RESULTS In total, 122 patients met criteria, 57 of which had MU on EGD and 65 who did not. The MU group had more smokers and patients with PPI use than the non-MU group, and the mean time from operation to CT scan was 26.6 months (range: 0-108 months). The MU group had a larger gastric pouch size than the non-MU group (34.1 ± 11.8 versus 20.1 ± 6.8 cm3). When analyzed for matched patient cohorts, this difference remained for the MU group that included smokers and PPI use. When stratified for pouch size, for each 5 cm3 increase in pouch size, patients had 2.4 times odds increase of MU formation. CONCLUSIONS CT volumetric analysis demonstrated that a larger gastric pouch size was associated with MU following RYGB.
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Affiliation(s)
- Sullivan A Ayuso
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA.
| | - Jordan N Robinson
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Leslie M Okorji
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Kyle J Thompson
- Division of Research, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Iain H McKillop
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Timothy S Kuwada
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Keith S Gersin
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Selwan D Barbat
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Roc W Bauman
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Abdelrahman Nimeri
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
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de Quadros LG, Faria DCG, Neto MG, Brunaldi V, Zotarelli Filho IJ, Faria MAG, Grecco E, Flamini Junior M, Martins SFS, Teixeira A, de Andrade CB, Ferraz AAB, Kaiser Junior RL. Banded RYGB Ring Slippage Endoscopic Removal with Self-expandable Stents: a Comparative Study Between Metallic and Plastic One. Obes Surg 2022; 32:115-122. [PMID: 34642873 DOI: 10.1007/s11695-021-05742-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/28/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Banded Roux-en-Y gastric bypass (RYGB) was a common bariatric procedure in the 2000s, and the ring slippage is one of its late adverse events. Both plastic and metallic stents have been reported as adjunct methods to induce erosion and facilitate endoscopic removal of the ring. OBJECTIVE To compare the safety and effectiveness of self-expanding metallic stents (SEMS) and plastic stents (SEPS) to treat ring slippage. MATERIALS AND METHODS We conducted a retrospective longitudinal study analyzing consecutive patients with ring dysfunction treated with stents plus endoscopic removal. RESULTS Ninety patients were enrolled (36 SEMS vs. 54 SEPS). The mean age was 48.56 ± 13.07 and 45.6 ± 12.1 in the SEMS and SEPS groups, respectively. All patients had band slippage, but 24 from SEMS group and 23 from SEPS group had further complications. There were more complications in metallic stent concerning mean absolute number of therapy-related adverse events (1.33 ± 0.48 vs. 1.72 ± 0.5, p > 0.05) and time until erosion (14.9 ± 1.6 vs. 13.8 ± 1.4 days, p > 0.05). Female sex and age > 41 years old correlated with longer time to band erosion and higher incidence of adverse events in SEMS patients. In SEPS group, only female sex was a risk factor for adverse events. CONCLUSION Both procedures were efficient at inducing band erosion with similar safety profiles. Older and female patients are at a higher risk of treatment-related adverse events, especially those receiving SEMS.
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Affiliation(s)
- Luiz Gustavo de Quadros
- Beneficencia Portuguesa Hospital, São Jose Do Rio Preto, Brazil.
- Faculty of Medicine of ABC, Santo André, Brazil.
- Faculty of Medicine of São José do Rio Preto, FAMERP, São José do Rio Preto, Brazil.
- Kaiser Clinic, Street XV de Novembro, 3975, Redentora, Sao Jose Do Rio Preto, SP, CEP 15015-110, Brazil.
| | | | - Manoel Galvão Neto
- Faculty of Medicine of ABC, Santo André, Brazil
- Endovitta Institute, São Paulo, Brazil
| | - Vitor Brunaldi
- Center of Gastrointestinal Endoscopy, Surgery and Anatomy Department, Ribeirao Preto Faculty of Medicine, University of Sao Paulo, Ribeirão Preto, Brazil
| | | | | | - Eduardo Grecco
- Faculty of Medicine of ABC, Santo André, Brazil
- Endovitta Institute, São Paulo, Brazil
- University of Sao Caetano Do Sul, São Caetano do Sul, Brazil
| | - Mario Flamini Junior
- Kaiser Clinic, Street XV de Novembro, 3975, Redentora, Sao Jose Do Rio Preto, SP, CEP 15015-110, Brazil
| | | | | | | | | | - Roberto Luiz Kaiser Junior
- Faculty of Medicine of São José do Rio Preto, FAMERP, São José do Rio Preto, Brazil
- Kaiser Clinic, Street XV de Novembro, 3975, Redentora, Sao Jose Do Rio Preto, SP, CEP 15015-110, Brazil
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12
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Lye TJY, Eng AKH. Late Stricture from Marginal Ulceration after Roux-en-Y Gastric Bypass: Endoscopic Complications and Surgical Management. Obes Surg 2021; 31:5508-5509. [PMID: 34570307 DOI: 10.1007/s11695-021-05716-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/03/2021] [Accepted: 09/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Tiffany Jian Ying Lye
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Outram Road, 169608, Singapore, Singapore.
| | - Alvin K H Eng
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Outram Road, 169608, Singapore, Singapore
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13
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Preoperative high-resolution esophageal manometry and postoperative symptoms in patients undergoing bariatric surgery: a retrospective cohort study. Surg Obes Relat Dis 2021; 18:85-94. [PMID: 34756565 DOI: 10.1016/j.soard.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The increasing incidence of obesity has led to a rise in bariatric surgeries. Obesity can be associated with various gastrointestinal symptoms as well as abnormal findings on high-resolution esophageal manometry (HRM). Bariatric procedures have variable effects on esophageal function and may contribute to postoperative symptoms. Preoperative HRM is not performed routinely on patients undergoing bariatric surgery but may identify patients likely to experience postoperative esophageal symptoms via delineation of structural or functional abnormalities. OBJECTIVES To evaluate whether prebariatric surgery HRM could predict persistent or de novo postoperative esophageal symptoms. SETTING Academic tertiary care hospital, United States. METHODS Retrospective data were collected for 20 patients undergoing HRM and 100 controls 18 years and older from May 2012 to May 2015. Propensity score matching was performed to adjust for baseline differences between the 2 groups. Preoperative and postoperative esophageal symptoms (reflux, dysphagia, nausea/vomiting, bloating, fullness, early satiety, pain, and intolerance) were compared between HRM and control patients, and associations among HRM findings, Chicago Classification, and symptoms were analyzed. All included patients had follow-up beyond 3 months postoperatively. Data were analyzed with 2-tailed Fisher's exact test, Wilcoxon rank-sum test, and odds ratio. RESULTS Compared to controls, patients undergoing preoperative HRM had a higher rate of postoperative chronic intolerance (25% versus 8%, P = .041). This difference was not observed in propensity score matching analysis. Identification of elevated integrated relaxation pressure and esophagogastric junction outflow obstruction predicted chronic intolerance (odds ratio = 21.0; 95% confidence interval: 1.40-314; P = .027 for each). CONCLUSIONS Preoperative HRM abnormalities were associated with postoperative symptoms in patients undergoing bariatric surgery. HRM can identify patients who are more likely to experience postoperative esophageal symptoms and may aid in discussion of suitability for surgery and selection of bariatric intervention.
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Farha J, Gebran S, Itani MI, Simsek C, Abbarh S, Lopez A, Haq Z, Koller K, Dunlap M, Adam A, Khashab MA, Oberbach A, Schweitzer M, Badurdeen D, Kumbhari V. Transoral outlet reduction: could additional sutures cause more harm? Endoscopy 2021; 53:1059-1064. [PMID: 33254242 DOI: 10.1055/a-1325-4324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The double purse-string pattern (DPSP) of transoral outlet reduction (TORe) should conceivably result in a more robust scaffolding for the gastrojejunal anastomosis (GJA). However, there is a paucity of literature pertaining to post-TORe stenosis as an adverse event. Our aim was to determine the rate of stenosis, its potential predictors, and other complications of DPSP TORe. METHODS We performed a retrospective analysis of a prospectively maintained database of 129 consecutive patients who underwent DPSP TORe between December 2015 and August 2019. RESULTS The adverse event rate of TORe was 17.1 % (n = 22), with a 13.3 % (n = 17) rate of stenosis. Stenosis was not significantly associated with any baseline characteristics. GJA diameter pre- and post-TORe, the difference between these values, and procedure duration were not predictive of stenosis. Of patients who developed stenosis, 10 (58.8 %) responded to endoscopic balloon dilation and 7 (41.2 %) required stent placement. CONCLUSION As the DPSP technique is a challenging procedure, with high complication rate and limited benefit, it should not be used for TORe.
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Affiliation(s)
- Jad Farha
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Selim Gebran
- Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland, United States
| | - Mohamad I Itani
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Cem Simsek
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Shahem Abbarh
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Ariana Lopez
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Zadid Haq
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Kristen Koller
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Margo Dunlap
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Atif Adam
- Department of Mental Health at The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Andreas Oberbach
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Diagnostics, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Michael Schweitzer
- Department of Surgery, The Johns Hopkins Center for Bariatric Surgery, Baltimore, Maryland, United States
| | - Dilhana Badurdeen
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, United States
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15
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Lynn PB, Pivo SE, Zaeedi ME, Parikh M, Saunders JK. Re-do Laparoscopic Gastrojejunostomy for Gastrojejunal Anastomosis Stricture After Roux-en-Y Gastric Bypass. Obes Surg 2021; 31:5506-5507. [PMID: 34533698 DOI: 10.1007/s11695-021-05711-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
Stricture of the gastrojejunostomy is a possible complication after laparoscopic Roux-en-Y gastric bypass. We present the case of a patient with stricture refractory to endoscopic dilation. The patient underwent laparoscopic revision of the gastrojejunostomy with a hand-sewn anastomosis.
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Affiliation(s)
- Patricio Bernardo Lynn
- Department of General Surgery, Bellevue Hospital/NYU Langone Health, 550 1st Avenue, New York, NY, 10016, USA
| | - Sarah Elizabeth Pivo
- Department of General Surgery, Bellevue Hospital/NYU Langone Health, 550 1st Avenue, New York, NY, 10016, USA
| | - Mohamed El Zaeedi
- Department of General Surgery, Bellevue Hospital/NYU Langone Health, 550 1st Avenue, New York, NY, 10016, USA
| | - Manish Parikh
- Department of General Surgery, Bellevue Hospital/NYU Langone Health, 550 1st Avenue, New York, NY, 10016, USA.
| | - John Kenneth Saunders
- Department of General Surgery, Bellevue Hospital/NYU Langone Health, 550 1st Avenue, New York, NY, 10016, USA
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16
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Gastrojejunal Anastomotic Stricture Following Roux-en-Y Gastric Bypass: an Analysis of Anastomotic Technique at a Single Institution. Obes Surg 2021; 31:4947-4952. [PMID: 34518993 DOI: 10.1007/s11695-021-05678-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) are at risk of developing strictures of the gastrojejunal anastomosis (GJA). Several variables can affect this, one of which may be the method of anastomosis. Between 2010 and 2014, our institution utilized three different anastomotic techniques for creating the GJA (25 mm end-to-end circular-stapled (CS), linear-stapled (LS), and robotic hand sewn (HS)). Our objectives were to compare the method of GJA relative to the subsequent development of anastomotic stricture. METHODS We queried our electronic health record for all patients who underwent an upper endoscopy (EGD) after RYGB (2010-2014). Patient charts were retrospectively reviewed for type of GJA, weight loss, complications, interventions, and revisions of the GJA. RESULTS In total, 1112 RYGB were performed at our institute, and 17.4% of patients (194/1112) had an upper endoscopy (EGD). Overall, 3.1% (34/1112) were found to have a stricture of the GJA. Patients undergoing a CS, LS, and HS anastomosis had GJA stricture rates of 4.9%, 0.5%, and 1.2% respectively (CS to LS (p < 0.05), p = NS among CS vs. HS, and LS vs. HS). The rate of GJA revision was 1.5%, 0.5%, and 0.1% (p = NS). In patients who had an EGD, excess BMI loss was 57.4%, 64.6%, and 59.2% (p = NS). In patients symptomatic from strictures, excess BMI loss was 69.4%, 83%, and 63.5% respectively (p = NS). CONCLUSION The anastomotic technique for creating of the GJA may impact the formation of strictures. Based on our experience, gastrojejunostomies created with a 2-mm EEA-stapling technique are at higher risk of strictures.
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Chen W, Chen I, Chen T, Hsu M, Tsai Y, Tai C. Endoscopic balloon dilation for gastrojejunal anastomotic stricture after
Roux‐en‐Y
gastric bypass: A case series. ADVANCES IN DIGESTIVE MEDICINE 2021. [DOI: 10.1002/aid2.13280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Wen‐Hsu Chen
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
| | - I‐Sung Chen
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
| | - Tzu‐Haw Chen
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
| | - Ming‐Hung Hsu
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
| | - Ying‐Nan Tsai
- Department of Internal Medicine E‐Da Cancer Hospital Kaohsiung Taiwan
| | - Chi‐Ming Tai
- Department of Internal Medicine E‐Da Hospital Kaohsiung Taiwan
- School of Medicine College of Medicine, I‐Shou University Kaohsiung Taiwan
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18
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Singh A, Aggarwal M, Siddiki H. Treatment of refractory benign gastroenteral strictures with fully covered metal stents. VideoGIE 2021; 6:308-310. [PMID: 34278093 PMCID: PMC8267956 DOI: 10.1016/j.vgie.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Video 1Treatment of refractory benign gastroenteral strictures with fully covered metal stents.
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Affiliation(s)
- Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manik Aggarwal
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Hassan Siddiki
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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19
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Castaneda D, Azar FF, Hussain I, Hasan B, Charles R, Pimentel R, Castro FJ. Clinical and Endoscopic Predictors of Hydrostatic Balloon Dilation Failure for Post-Bariatric Anastomotic Stricture Treatment. Obes Surg 2021; 31:2935-2941. [PMID: 33761069 DOI: 10.1007/s11695-021-05353-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/06/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) patients can develop anastomotic strictures. The initial management relies on endoscopic hydrostatic balloon dilation, but in a subset of patients, it may be unsuccessful despite several dilations, requiring a different treatment modality. We evaluated the factors associated with balloon dilation failure and need for revision surgery. METHODS Retrospective analysis from patients presenting with a post-RYGB anastomotic stricture who underwent balloon dilation from 2005 to 2018 at Cleveland Clinic Florida and Cleveland Clinic Main Campus. Demographic, clinical, surgical, endoscopic, and post-procedural variables were collected. Univariate and multivariate analysis with odds ratio (OR) and 95% confidence interval (95% CI) calculation for factors associated to dilation failure was performed. RESULTS Eighty-nine patients were included in the analysis. Population was predominantly white (85.4%) and female (87.6%), with mean age 46.4 years and followed for a mean of 97.4 months. All patients presented dysphagia, with mean stricture diameter of 7.7 mm and associated marginal ulcer in 69%. Successful dilation was achieved in 65 patients, while 24 patients had dilation failure and underwent revisional surgery. Multivariate analysis showed a higher risk of dilation failure if time from RYGB to first dilation was >3 months (OR 4.95, 1.29-19.04; p = 0.02), and if nausea/vomiting were present before first dilation (OR 4.37, 1.11-17.16; p = 0.03). One patient had a perforation after dilation and was treated surgically. CONCLUSIONS Post-RYGB anastomotic strictures can be successfully treated with hydrostatic balloon dilation. However, patients with dilations performed > 3 months after initial RYGB and nausea/vomiting have an increased risk of dilation failure and need for further interventions.
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Affiliation(s)
- Daniel Castaneda
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA.
| | - Francisco Franco Azar
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Ishtiaq Hussain
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Badar Hasan
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Roger Charles
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Ronnie Pimentel
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
| | - Fernando J Castro
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33027, USA
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20
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Comparison of gastrojejunostomy techniques and anastomotic complications: a systematic literature review. Surg Endosc 2020; 35:6489-6496. [PMID: 33159295 DOI: 10.1007/s00464-020-08142-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 10/27/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND There are several ways to perform the gastrojejunostomy (GJ) anastomosis in laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgeons typically use a variation of three techniques: Hand-sewn anastomosis (HSA), Linear stapled (LS) and Circular stapled anastomosis (CSA). The purpose of this literature review is to determine which of the GJ techniques, if any, is superior and results in the least amount of postoperative complications, with a specific focus on rates of marginal ulcers, postoperative bleeding, and strictures. METHODS PubMed, Embase, and Cochrane electronic databases were consulted for studies on LRYGB procedures utilizing a GJ anastomosis, from January 1, 2015 to December 31, 2019. Cochrane and PRISMA screening methods were used to select the studies. RESULTS Eleven studies published between 2015 and 2019 were selected and included 135,899 patients that underwent LRYGB with a GJ anastomosis. Sample sizes ranged from 114 to 49,331 patients. Four studies reported that CSA had statistically significant higher rates of marginal ulcers when compared to HSA and LS techniques. Three studies concluded that CSA had statistically significant higher rates of postoperative bleeding when compared to HSA and LS. Five studies observed that CSA had statistically significant higher rates of strictures when compared to HSA and LS techniques. There was no consensus whether HSA or LS was superior in terms of reduced postoperative complications. CONCLUSION This study revealed statistically significant increases in rates of postoperative bleeding, marginal ulcer, and strictures with the use of mechanical circular staplers at the GJ anastomosis in LRYGB. Based on our results, avoiding the use of mechanical circular staplers can result in fewer postoperative complications. Nevertheless, there are limitations to retrospective studies which may influence the results and therefore a randomized controlled trial directly comparing HSA, CSA, and LS should be performed to truly determine which technique is superior.
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21
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3: ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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22
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Management of Esophageal Achalasia after Roux-en-Y Gastric Bypass: Narrative Review of the Literature. Obes Surg 2020; 29:1632-1637. [PMID: 30778843 DOI: 10.1007/s11695-019-03774-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The development of achalasia after Roux-en-Y gastric bypass (RYGB) is rare. Heller myotomy (HM) is the gold standard treatment while peroral endoscopic myotomy (POEM) is an emerging technique with promising results. The aim of this narrative review was to summarize the current knowledge on the treatment of esophageal achalasia after RYGB. METHODS PubMed, EMBASE, and Web of Science databases were consulted. All articles that described the management of achalasia after RYGB were included in this narrative review. RESULTS Twelve studies for a total of 28 patients were included. The age of the patient population ranged from 44 to 70 years old and 80% were females. Overall, 61.5% underwent laparoscopic RYGB while 38.5% underwent open RYBG. The elapsed time from the RYGB to myotomy ranged from 14 months to 14 years. Dysphagia (64%) and regurgitation (60.7%) were the most commonly reported symptoms; type I achalasia was diagnosed in 50% of patients. Surgical HM was performed in 17 patients (61%) while POEM was performed in 11 patients (39%). Postoperative morbidity was 3.6% with no differences comparing surgical HM and POEM (6% vs. 0%, p = 0.43). The follow-up time ranged from 1 to 43 months. The overall recurrence rate requiring reoperation was 7% with no differences comparing surgical HM and POEM (12% vs. 0%; p = 0.25). CONCLUSION Both HM and POEM seem feasible, safe, and effective in the management of achalasia after RYGB. The role of POEM in the management algorithm of these patients should be further evaluated.
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Diaz-Vico T, Elli EF. Value of robotic-assisted technique in redo gastrojejunostomy for severe stenosis after gastric bypass. J Robot Surg 2019; 14:463-471. [PMID: 31463879 DOI: 10.1007/s11701-019-01009-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/05/2019] [Indexed: 12/11/2022]
Abstract
Development of gastrojejunal stricture following Roux-en-Y gastric bypass (RYGB) leads to an increase in morbidity and adverse effects, such as abdominal pain, vomiting, aspiration pneumonia, and malnutrition. Up to 38.5% of patients will require revisional surgery for late anastomotic strictures despite conservative treatment. However, no previous studies focused on revisional robotic bariatric surgery due to strictures after RYGB have been reported. To evaluate our outcomes and assess the advantages of the robotic platform with regard to laparoscopic and open revisional procedures. University Hospital. We performed a retrospective analysis of patients who underwent laparoscopic robotic-assisted redo gastrojejunostomy from 2016 to 2018. Demographics, surgical data, medical treatments, postoperative outcomes, and adverse effects were collected. Nine patients with symptomatic anastomotic strictures after primary RYGB underwent robotic revisional surgery. All patients received medical therapy as a first approach, and five patients (55.5%) underwent endoscopic balloon dilation. All procedures were successfully completed with robotic assistance, with a mean (standard deviation) operative time of 184.5 (49.1) min, and no intraoperative adverse effects were registered. Median (range) hospital stay was 2 (1-4) days. One patient presented with a postoperative intra-abdominal abscess and was treated with intravenous antibiotics and image-guided drainage. No anastomotic leak, hemorrhage, or mortality were reported. Robotic assistance seems to be safe and effective for redo gastrojejunostomy secondary to stricture. Even though the sample size is small, we believe that the application of robotic techniques may provide advantages and improve the outcomes in these complex revisional procedures.
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Affiliation(s)
- Tamara Diaz-Vico
- Division of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
| | - Enrique F Elli
- Division of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
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Mechanical factors in the prediction of integrity of the gastrojejunal anastomosis in ex-vivo RYGB models. Surg Obes Relat Dis 2019; 15:887-893. [PMID: 31103362 DOI: 10.1016/j.soard.2019.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 02/13/2019] [Accepted: 03/01/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgical staplers represent one of the important instruments in modern surgery. Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric procedures. Various techniques have been described for performing gastrojejunal (GJ) anastomosis, including linear stapled anastomosis (LSA), circular stapled anastomosis (CSA) and hand-sewn anastomosis (HSA). OBJECTIVES An ex-vivo porcine-based experiment was designed to compare the mechanical integrity of the GJ anastomosis among the 3 different techniques by measuring burst pressure (BP). SETTING Laboratory-based study conducted at the clinical skills laboratory at Birmingham Heartlands Hospitals, Birmingham, United Kingdom. METHODS Porcine stomachs and small bowels were used to create a GJ model. Four GJ anastomosis models each were created using circular stapler (CSA group) and hand-sewn techniques (HSA group). Stomach and small bowel thickness were recorded. BP was measured by sequential injections of methylene-blue diluted saline until a leak was detected. Total volume until leak is recorded. Compliance (C) was calculated using the formula C = ΔP/ΔV. RESULTS Results from our previous experiment for the LSA group are included. One model was excluded from the CSA and the HSA groups due to technical errors. Results were presented as mean ± standard deviation. Total volume in LSA, CSA, and HSA groups was 60 ± 4.08 mL, 73.67 ± 3.22 mL, and 51.67 ± 20.21 mL, respectively. BP in LSA, CSA, and HSA groups was 18 ± 4.69 mm Hg, 20.33 ± 5.77 mm Hg, and 9.67 ± 3.79 mm Hg, respectively. There was a statistically significant difference in BP among the 3 groups (P = .033; Kruskal-Wallis test). C in LSA, CSA, and HSA were 3.50 ± .88 mm Hg/mL, 3.78 ± .85 mm Hg/mL, and 5.39 ± 1.34 mm Hg/mL, respectively (P = .064). CONCLUSION BP was higher in CSA and LSA groups compared with the HSA group, suggesting a mechanically stronger anastomosis. Despite the lack of statistical significance, higher BP recorded in the CSA group than in the LSA group suggests better anastomotic integrity.
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